Peer Review
by Dunnage41
Summary: Practicing physicians - even those whose patients are no longer living - face a lot of licensure requirements.


_Although Henry provided an explanation for his degree from Guam in Episode 18, "Social Engineering," the flashbacks for this fic have been knocking around in my head for too long to undo._

Jo's usual brisk stride stuttered to a halt. Lucas was hovering over a body – but Henry was … Jo looked around … in his office, a stack of folders and papers at his elbow.

"Ah, Detective Martinez, come in," Henry said, without looking up. "If you need a medical examiner at a scene, Lucas will gladly accompany you."

Jo said nothing. Somehow the silence spoke volumes, because it broke Henry's concentration and he looked up.

"I am sorry," he said, waving an arm over the paperwork. "All of this must be completed and mailed by the twenty-first of April."

"All of what, Henry?" Jo asked, curiously. She leaned over, trying to read upside down.

"Take your pick," Henry replied. "Continuing medical education requirements from the American Medical Association to keep my license current"—he lifted one folder from the stack – "Continuing medical education requirements for the State of New York, ditto"—he lifted another folder – "and for the city"—a third folder. He set the folders on the other side of the desk and continued.

"To remain board-certified in pathology, proof of 70 of my AMA continuing medical education requirement hours plus twenty self-assessment modules"—he gestured to yet another folder—"laboratory performance improvement and quality assurance, proof of laboratory accreditation, annual inspection certificates from the city, county, and state, and finally" – he stood up and winced as he arched his back – "I want to make sure I have all the paperwork in order in the next two and a half hours, because the head of pathology at Columbia-Presbyterian is coming by for a peer evaluation." He raised his eyebrows.

"All of which reminds me: We have Mr. Santorrio on the table, here, but if you could possibly come back at 11 o'clock, we'll begin as if from the beginning, to give Dr. Campenot an opportunity to observe and take notes on not only the autopsy itself but also on – ahem – my interpersonal communication skills." He looked thoroughly discomfited.

It was only with difficulty that Jo bit back a smile.

Covering his embarrassment with pomposity, Henry quoted: " 'All diplomates are required to provide peer attestations as to their interpersonal and communication skills, professionalism, ethics, and effectiveness in systems-based practice.' In addition, Dr. Campenot will also be interviewing Lucas, other staff, and several other pathologists in the city."

Jo blinked. "Jeez, Doc," said Hanson's voice behind her, "All we gotta do is 20 hours a year of continuing ed and basic fitness and firearms tests." He gestured to the table. "Sounds like you could make a full-time job just out of keeping your paperwork up. So what you're saying is, you don't want to look at Mr. Santorrio, here, until your 'peer eval-u-a-tor' shows up." He rolled his eyes.

"Essentially, yes," Henry said. "For the autopsy to be appropriately peer-reviewed, I am not allowed to have previously examined the body."

"Yup, gotta start cold," Lucas agreed cheerfully, earning That Look from Henry.

"What does a medical license look like, anyway?" Jo asked. She had noticed no framed diplomas on the walls in Henry's office – modesty, she had thought, once she got to know a little about him. "Does it look like, you know, a diploma?"

"No," Henry replied, obediently flipping through folders. "Like this." He held up the small, flimsy rectangle of paper that looked a lot like the victualler's licenses Jo had seen in restaurants or the license to sell liquor displayed in bars. It had a seal of the State of New York, an expiration date, a license number, and Henry's name on it, along with the words "NY Department of Labor, Licensing, and Regulation."

"So what does your actual diploma look like, Doc?" Hanson had stepped into the office itself and was looking over Jo's shoulder.

Henry found another folder. "Like this." He handed it over and Jo and Hanson studied it.

"University of Northern Guam," it read. "Upon the recommendation of the faculty of The College of Medicine, has conferred upon Henry William Morgan the degree of Doctor of Medicine with all its rights, honours, and responsibilities. In witness whereof we have caused the seal of the university to be affixed this Eighteenth day of May, Two Thousand Four."

Henry watched them read the diploma, his expression unchanging, but his imagination shot back to a humid July afternoon in 2005. He, Abraham, and a third man – "Call me Jules" – had sat in the very back booth of a back room of an inconspicuous private club hidden behind an unmarked, heavily over-painted gray steel door.

"Jules" had nodded at Abraham. "You got it?"

Abe had pulled out an envelope. Jules pulled out the thick wad of cash. Henry automatically glanced around the room: they were the only ones there, though he could hear the sounds of pool players and drinking from the bar in the front of the building.

Jules slowly and calmly counted the money, twice, then nodded and stowed it away. He shoved a manila envelope across the table to Abe, who spilled out the documents. Henry, keyed up but curious nonetheless, looked them over:

A birth certificate showing that one Henry Morgan had been born in London at St. Batholomew's Hospital on the 7th of September in 1979, weighing 8 pounds 10 ounces. A diploma from The Rokeby School, London, dated 1998. One from State University of New York-Binghamton showing him to be a 2001 graduate.

Jules tapped the birth certificate and the Rokeby diploma with thick, permanently stained fingers. "That's why this was so, uhh… costly." He winked. "Hadda work with an associate over there."

With trembling fingers, Henry lifted aside the SUNY-Binghamton diploma, and there it was. The diploma from the University of Northern Guam College of Medicine, which didn't exist. The college itself was real enough; it just had no medical school.

"And that's the other gold piece," Jules said, poking a stubby, stained finger at the paper Henry held. "Looks good, though, right? Like the real deal."

He grew serious, staring at Henry so hard that Henry squirmed. "I don't know what you're up to," he said. "I don't care. None-a-my business. You wanna practice medicine without a license, be my guest." He stood abruptly, and Henry could see the firearm barely concealed within a shoulder holster.

"Our business is done," he said, scooping up a filthy cabbie's cap and slapping it on his head. "I ain't never heard-a youse. I don't need to say 'or else' … do I?" He winked again, and the smile and the twitch turned his face grotesque, a Tyl Uilenspiegel mask.

"No. You don't," Abe said. He slid the papers back into the envelope as quickly as he could manage and put an arm around Henry, steering him toward the exit.

"Look," Abe said in the cab. "You know good and well you're not practicing medicine without a license. You have a perfectly legitimate diploma … from Oxford University, no less. It just happens to date to 1795 and not 2005."

Henry sighed. He was just glad the whole business was over. He knew intellectually that Abe was correct. He had, in fact, received the top medical education one could get – for the late eighteenth century. Hyperaware that much of what he had learned in the classroom was not just outdated but incorrect, as medical knowledge had advanced, he had striven to keep that knowledge current across the centuries. He devoured medical journals, took copious notes at continuing education events, and made sure his knowledge was as updated as he could make it.

Still, though his brain told him otherwise, his heart shouted, "Fraud." He was now in possession of diplomas that he had not earned – and in one case, at least, from a school that did not exist. He loathed the dishonesty that walked hand-in-hand with his condition, even as he depended on subterfuge, concealment, and outright lies to keep himself and Abe safe. _Do you have a child? No. Are you married? No. Where did you study? Guam. _He sighed. Abe glanced over at him.

"So what's it like?" Hanson's voice penetrated Henry's fog.

"Hm?"

"What's it like? Guam?"

Henry blinked. "Humid."

"I, uh … wasn't really askin' about the climate." Hanson raised his eyebrows and smirked.

"Ah, yes." Henry caught on. "The students who paid attention to the bars and the women didn't last very long."

"You mean you actually went to classes and everything? Like a real med school?"

Henry knew the detective was needling him, which allowed him to feel legitimately defensive. It wasn't the instinctive guarding of his secret that was ruffling him at the moment; he actually felt compelled to defend the honor of an institution that did not exist. Some small detached part of his mind was deeply amused at the farce.

"It was … and is … a real medical school, Detective," Henry said, drawing himself up to his full height. "It has been duly accredited by the Association for Accreditation of Medical Schools and Colleges, and I can assure you its curriculum meets their standards."

Hanson chuckled to himself. Henry was always funny when he got puffed up over nothing. "So why'd you go there, anyway? You're super-smart, right? Why not, I dunno, Harvard or something?" He was no longer needling but genuinely curious. Henry's superior intelligence routinely left him in the dust, and he was, on occasion, tired of feeling subnormal around the medical examiner. He assumed that Henry, being Henry, could have strolled into any medical school he wanted.

"The medical school acceptance rate is somewhere between 3 percent and 9 percent … a little higher at state schools," Henry explained, sitting back down. "I was a decent student, but I hadn't really thought about becoming a doctor until fairly late in my undergraduate career. I didn't have the clinical experience, impressive list of charitable work, or connections."

"How can you get clinical experience before you get into med school?" Jo asked.

"Clinical experience such as shadowing a physician for a semester or a year, or doing volunteer work in a hospital lab, is generally expected nowadays among medical schools. It helps prove your dedication and is meant to minimize the number of students becoming ill on their first day in the dissection lab."

"After I was turned down at no fewer than eleven medical schools, an acquaintance suggested I think outside the box… that is, outside the mainland United States."

"Okay, lemme ask you this, Doc," Hanson said, picking up a handful of files from Henry's desk. "You gotta do all this paperwork every year, right? What about some doc who went to Columbia?"

Henry smiled. "Yes, the licensure upkeep requirements are the same for everyone who holds a medical degree and a license to practice medicine. Doesn't matter where one obtained that degree." He drew out his pocket watch and raised his eyebrows. "Now. If you all will excuse me, I have just over two hours to ensure that all of this is in order." He stood. "Was there anything else?"

"We were actually coming by for Mr. Santorrio," Jo said, but we can come back at … when is it? Eleven? Will we have to do anything different for your evaluator?"

"No," Henry said. "It will be a standard autopsy. In fact, please do ask any questions that you would have asked. As I said, part of what Dr. Campenot will be observing will be my interactions with colleagues."

Henry watched the detectives walk away. He turned to Lucas. "Lucas, we've discussed this," he said gravely.

"I know, I know." Lucas put his hands up in surrender. "No lettin' my freak flag fly. Just keep it simple, quiet, and serious."

"No. Jokes." Henry said. "I cannot emphasize this enough. This is not a joking matter. In the worst case, I could lose my license."

"Yes. Okay. Got it," Lucas said. He strode cheerfully away, and as he often did, Henry marveled at Lucas' ability to let everything bounce off of him. Nothing seemed to get Lucas down. How many other assistant M.E.s would not only have captured those rats, but resectioned the bowels of one of them, simply to ease its immediate suffering? And then there was the liver sample he'd sneaked in and obtained from Gloria Carlyle.

Suddenly drained, Henry sat down behind his desk and ignored the folders. He'd been rehearsing the entire scenario for a decade, ever since obtaining the paperwork that showed him to be a graduate of a medical college in Guam. He and Abe had talked out the backstory, come up with convincing explanations for his failure to go to school in the mainland United States, researched acceptance rates and read up on why people failed to be accepted into medical schools. It was exhausting and hairsplitting, and one of the challenges of hauling around such an incredible secret. And now at last someone had extracted it, given him his cue, and he had delivered the speech, and the audience had found it convincing. He sighed deeply and began sorting the folders. He had to neaten his desk – quite a bit, actually – and ensure that the paperwork was ready.

At four minutes past eleven, introductions made, Henry reminded himself to keep it simple, not to be overly clever, and to actually look closely at the body before announcing any findings.

"The subject in question is a seventy-nine-year-old Caucasian male, height five feet ten inches, weight two hundred seventeen pounds. Neighbors heard shouting, witnessed a neighbor leave his apartment, called the super, who unlocked the door and discovered the subject lying on his bead apparently deceased. They then phoned the police and this office, and Lucas pronounced the subject dead at the scene. At the discovery, upon recording of the core temperature of the body and taking into account the environmental factors, the subject had died approximately twenty minutes previously.

"There is the question of whether the altercation was physical and whether the altercation was a proximate or contributing cause of death," Henry continued.

He adjusted the light and closely examined the face. "No signs of bruising," he said. "No visible contusions or lacerations." He moved the light again and picked up an arm. "Along the right forearm, no visible contusions or lacerations. No signs of defensive wounds." He carefully examined the nails. "No indications of debris or foreign objects under the nails." He continued with the other arm. "The same is true bilaterally," he said.

"No signs of strangulation. Petechiae not present in the eyes; no indication of trauma to the hyoid bone. Collarbones are intact and not dislocated; no visible contusions or lacerations on the torso." He straightened. "Detectives, I see no immediate indications of a physical alteration."

Jo made a point of looking through her notes, hoping the evaluator noticed. "Neighbors said only that they heard yelling. The neighbor who left—" Henry held up a hand.

"I'm sorry to interrupt, Detective," Henry said gently. "Please don't tell me anything about the neighbor who was present in the apartment until after I've completed the autopsy."

"Of course, Doctor," Jo said, feeling as though she were reciting lines in the school play.

Henry proceeded with his examination of the outer body, finding no signs of trauma, then asked Lucas to open the skull, weigh the brain, and examine a tissue sample under the microscope. While he did that, Henry made the Y-shaped incision in the torso and folded back the chest flesh, then used the pruning shears to clip open and remove the ribcage. Hanson paled slightly but steadied himself on his feet.

"Lucas?" Lucas had returned. With careful formality and none of his usual casual breeziness, Lucas said, "Brain weight of 2.7 pounds slightly below normal. As well, the tissue sample showed signs of mild development of amyloid plaque, leading to a conclusion that the subject had developed early stages of dementia."

"Thank you," Henry said. "Would you please remove the heart."

Hanson swallowed hard and averted his eyes as Lucas neatly sliced out the heart and held it for Henry.

"Ah, here we go," Henry said. "The muscular tissue of the left ventricle is visibly necrotic. Lucas, if you would be so kind as to take a sample from the left ventricle."

"How can you tell?" Jo asked, while Hanson said, "What's that mean, 'necrotic'?"

Henry smiled and turned to address the detectives. " 'Necrotic' means dead, and I can tell because the tissue of the left ventricle is visibly bright red, instead of the more muted grayish-red of healthy cardiac tissue. It's a possible indicator of myocardial infarction, or a heart attack." He sharpened his gaze as Jo looked about to speak. She caught her breath and said nothing.

While Lucas examined the tissue, Henry proceeded to palpate the lungs and other organs. He withdrew a tissue sample from the right lung and set it aside. He removed the liver and examined it, drained the stomach contents for analysis, and palpated the bladder, keeping a running commentary as he did for the wall-mounted recorder. "Lungs show evidence of consistent tobacco use… fatty liver shows evidence of a stiff consistent use of beverage alcohol…" he paused to remove a tissue sample of the liver and set that aside.

"Ah, Lucas," he said at last.

"Yup," Lucas said, then cleared his throat. "Ahem. Uh, I sliced the left ventricular area to display the muscle wall, which showed yellow, as would be expected from the visibly necrotic appearance upon first examination."

Lucas cleared his throat again and continued. "Upon that discovery, I extracted other cardiac tissue samples, finding evidence of atherosclerosis consistent with myocardial infarction."

"Excellent, thank you," Henry said. He handed Lucas the liver and lung tissue. "Which one would you like?"

"Uh, I'll take the lung." Henry handed the sample to Lucas and headed to one of the other scopes with the liver tissue. The silence hung heavily. Eventually they met back at the body.

Henry nodded at Lucas.

"The subject was a regular and heavy smoker," Lucas reported. "Lung tissue shows evidence of decades of cigarette use."

Henry nodded. "Liver tissue confirms that the subject was also a regular and heavy drinker, and in fact shows early stages of cirrhotic development. If you don't mind analyzing the stomach contents, I believe we're nearly done."

Henry puttered with the body, re-examining the fingernails, turning the neck, even looking in the ears, while waiting. Hanson shot Jo a look. Jo raised her eyebrows and kept her expression blank.

"Not much in the stomach," Lucas reported. "Mostly bile. A few grams of coffee."

"Thank you," Henry said. He turned again and faced the detectives. "The medical indications are that this individual was at increased risk of heart attack from his age, his gender, his weight, his alcohol and tobacco habits, his sedentary lifestyle, and his dietary habits; that he in fact had a heart attack; did not receive treatment; and subsequently died," he said. His expression invited Jo to add anything.

Jo cleared her throat and again consulted her notebook. "Well. Ahem. Uh, the neighbor reported that he came by to play chess with the deceased, they got into an argument about a fellow neighbor whom they both, um, were fond of, and that the guy, the deceased, abruptly waved his arms and said, 'Ah, I'm tired. You better go.'"

"The neighbor asked him if he was all right, and the deceased said, 'I'm tired. Gonna lie down.' The neighbor said he was sorry and let himself out. He then left the building to go buy some cigars and when he came back, the police were there."

Henry shrugged. "I suppose one could argue that the stress of the argument with an old friend might have contributed to the heart attack – but that's another matter. In fact, the decedent's waving his arms and reporting fatigue are consistent with a heart attack. My findings are that the cause of death was myocardial infarction and the manner of death was natural." He peeled off his gloves and extended his hand to Jo and then to Hanson.

"Thank you, detectives," he said formally. Jo and Hanson paused, then Jo replied:

"Thank you, Doctor Morgan. Lucas."

Dr. Campenot spoke for the first time. "Gentlemen, ma'am, thank you. She nodded at Lucas and the detectives. "Please fill in this form completely and truthfully; the forms will be separated from any identifying factors before the statements are considered. I will submit my recommendation directly to the American Board of Pathology within six days." She strode briskly from the lab.

"You mean that's it?" Hanson finally asked, breaking the silence.

"That's it," Henry agreed. He shrugged. "It's nerve-wracking, yes, but all the same it's largely a formality."

Jo looked over the form. "It's just a … well, a collegial evaluation. Asking for any observations of inappropriate behavior, any manner of death that we disagreed with or that our subsequent investigations proved incorrect…"

Hanson and Jo exchanged a look. "You're different from any other M.E. I've worked with… but you're incredibly good at what you do," Jo said. "I have no problem filling this out."

"Yeah, uh, me too, Doc," Hanson said. "And Mr., uh, Santorrio … died of a heart attack? Really? That's all? No, uh, polonium poisoning? No fountain-pen stabbing?"

Henry smiled. "Textbook heart attack – from a textbook likely victim." He nodded toward the body and ticked off the risk factors on his fingers. "Overweight, smoker, drinker, older, male."

He looked around at his colleagues … his friends. "Now. If there's nothing more – lunch is on me."

As he strode toward the elevator, not waiting for a reply, he thought he heard Lucas say, "Not Taste of Urkesh."

*Credit Joe McGinnis, Cruel Doubt, for the phrasing of "stiff consistent use of beverage alcohol."


End file.
